unruptured middle cerebral artery aneurysm in a patient with systemic lupus erthematosus: a diagnostic challenge

a 22-year-old female patient presented to the emergency department of a tertiary care hospital with symptoms of headache and nausea. she has been on a regular follow-up for the preceding three and a half years after being diagnosed as systemic lupus erythematosus (sle). she had been treated earlier for sle nephritis in the same institution, and had two relapses of nephrotic syndrome in the last three and a half years for which she had been treated and had achieved complete remission. all possibilities of headaches in background of sle were considered. cns examination was inconclusive. there was no nuchal rigidity or no cranial nerve deficits. fundoscopy and plain ct scan of brain were normal. the possibility of cns-lupus was considered considering the high values of antiphospholipid antibodies (apla). treatment was initiated accordingly; however, there was no improvement in her symptoms. although being rare in a patient with sle, the possibility of an aneurysm was considered. four vessel digital substraction angiography revealed two unruptured aneurysms of 7.2 mm and 3.9 mm in the left middle cerebral artery (mca) territory. craniotomy and aneurysmal clipping was done successfully, and the patient was relieved of her symptoms. a high degree of suspicion towards a rarer cause clinched the diagnosis of a left mca territory stem artery aneurysm. this rationale of strong suspicion and discussion of differential diagnosis brought a change in the management of the patient.